Subarachnoid Hemorrhage(SAH)

Ionuţ Cărăvan Coordinated by Prof. Ioan Ştefan Florian, MD, PhD

University of Medicine and Pharmacy “Iuliu Haţieganu“ Cluj Napoca

Definition

• SAH = extravasation of blood into the subarachnoid space

Etiology

Greenberg Handbook of Neurosurgery, 2010

Traumatic SAH Non-traumatic (spontaneous) SAH

o ruptured intracranial aneurysms (75 %)oAVM (5 %)oothers (tumor, vasculitis, coagulation disorders, dural

sinus thrombosis)ounknown etiology (15 %)=“angiogram-negative SAH”

Presenting features(1)

• HEADACHE (“thunderclap headache”)• meningismus

neck stiffness photophobia back pain

Presenting features(2)

• decreased state of consciousness• nausea and vomiting• seizures• focal neurologic deficits:

oculomotor palsy hemiparesis

• ocular hemorrhage

Radiographic findings

• CT scan• Cerebral Angiography• FLAIR* MRI• CT Angiography• MRA**

*Fluid-attenuated inversion recovery**Magnetic Resonance Angiography

CT scan

Lumbar puncture

Grading SAH

Hunt and Hess Grade WFNS* Grading

*World Federation of Neurological Surgeons

Complications

• Hydrocephalus• Vasospasm => delayed cerebral ischemia • Seizures• Rebleeding• Intracerebral hemorrhage• Intraventricular hemorrhage• Left ventricular systolic dysfunction• Subdural hematoma

Treatment

• BP control (fluid restriction and antihypertensive therapy) when the mean arterial pressure exceeds 130 mm Hg

• ICP control (osmotic agents, loop diuretics)

• Symptomatic treatment: – anticonvulsants: levetiracetam, phenytoin– analgesics: fentanyl– anti-emetics: odansetron– calcium channel blockers: nimodipine, verapamil => vasospasm

!!! Prevention of rebleeding:

• antifibrinolytic therapy • surgical treatment • endovascular treatment

References

• MS Greenberg. Handbook of Neurosurgery. Seventh Edition. New York: Thieme Medical Publishers; 2010.

• AH Kaye. Essential Neurosurgery. Third Edition. Oxford: Blackwell Publishing Ltd; 2005.

• MG Yasargil. Microneurosurgery. New York: Thieme Medical Publishers Inc; 1994.

Thank you!